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Endoscopic treatments for cancer of the esophagus

Several types of treatment for esophageal cancer can be done by passing an endoscope (a long, flexible tube) down the throat and into the esophagus. Some of these treatments may be used to try to cure very early stage cancers, or even to prevent them from developing by treating Barrett’s esophagus or dysplasia. Other treatments are used mainly to help relieve symptoms from more advanced esophageal cancers that can’t be removed.

Endoscopic mucosal resection

Endoscopic mucosal resection (EMR) is a technique where a piece of the inner lining of the esophagus is removed with instruments passed down the endoscope. EMR can be used for dysplasia (pre-cancer) and some small, very early-stage cancers of the esophagus.

After the abnormal tissue is removed, patients take drugs called proton pump inhibitors to suppress acid production in the stomach. This can help keep the disease from returning.

The most common side effect of EMR is bleeding in the esophagus, which is usually not serious. Less common but more serious side effects can include esophageal strictures (areas of narrowing) that might need to be treated by with dilation, and puncture (perforation) of the wall of the esophagus.

Photodynamic therapy

Photodynamic therapy(PDT) is a method that can be used to treat Barrett’s esophagus, esophageal pre-cancers (dysplasia), and some very early stage esophageal cancers.

PDT is also often used to treat large cancers that are blocking the esophagus. In this situation, PDT is not meant to destroy all of the cancer, but to kill enough of the cancer to improve a person’s ability to swallow.

For this technique, a light-activated drug called porfimer sodium (Photofrin®) is injected into a vein. Over the next couple of days, the drug is more likely to collect in cancer cells than in normal cells. A special type of laser light is then focused on the cancer through an endoscope. This light changes the drug into a new chemical that can kill the cancer cells. The dead cells may then be removed a few days later during an upper endoscopy. This process can be repeated if needed.

The advantage of PDT is that it can kill cancer cells with very little harm to normal cells. But because the chemical must be activated by light, it can only kill cancer cells near the inner surface of the esophagus – those that can be reached by the light. This light cannot reach cancers that have spread deeper into the esophagus or to other organs.

PDT can cause swelling in the esophagus for a few days, which may lead to some problems swallowing. Strictures (areas of extreme narrowing) can also occur in some patients. These often need to be treated by with dilation. Other possible side effects include bleeding or holes in the esophagus.

Some of this drug also collects in normal cells in the body, such as skin and eye cells. This can make you very sensitive to sunlight or strong indoor lights. Too much exposure can cause serious skin reactions, which is why doctors recommend staying out of any strong light for 4 to 6 weeks after the injection.

This treatment can cure some very early esophageal cancers that have not spread to deeper tissues. But this procedure destroys the tissue, so it can be hard to be certain that the cancer hasn’t spread into deeper layers of the esophagus. Since the light used in PDT can only reach those cancer cells near the surface of the esophagus, cells of deeper cancers could be left behind, and grow into a new tumor. People getting this treatment need to have follow-up endoscopies to make sure the cancer hasn’t grown back. They also need to stay on a drug called a proton pump inhibitor to stop stomach acid production.

Radiofrequency ablation (RFA)

This procedure can be used to treat dysplasia in areas of Barrett’s esophagus. It may lower the chance of cancer developing in that area.

A balloon containing many small electrodes is passed into an area of Barrett’s esophagus through an endoscope. The balloon is then inflated so that the electrodes are in contact with the inner lining of the esophagus. Then an electrical current is passed through it, which kills the cells in the lining by heating them.

Over time, normal cells will grow in to replace the Barrett’s cells. The patient needs to stay on drugs to block stomach acid production after the procedure. Endoscopy (with biopsies) then is done periodically to watch for any further changes in the lining of the esophagus. Rarely, RFA can cause strictures (narrowing) or bleeding in the esophagus.

Laser ablation

This technique can be used to help open up the esophagus when it is blocked by an advanced cancer. This can help improve problems swallowing.

A laser beam is aimed at the cancer through the tip of an endoscope to destroy the cancerous tissue. The laser is called a neodymium: yttrium-aluminum-garnet (Nd:YAG)laser. Laser endoscopy can be helpful, but the cancer often grows back, so the procedure may need to be repeated every month or two.

Argon plasma coagulation

This technique is similar to laser ablation, but it uses argon gas and a high-voltage spark delivered through the tip of an endoscope. The spark causes the gas to reach very high temperatures, which can then be aimed at the tumor. This approach is used to help unblock the esophagus when the patient has trouble swallowing.

Electrocoagulation (electrofulguration)

For this treatment, a probe is passed down into the esophagus through an endoscope to burn the tumor off with electric current. In some cases, this treatment can help relieve esophageal blockage.

Esophageal stent

A stent is a device that, once in place, self-expands (opens up) to become a tube that helps hold the esophagus open. Stents are made of mesh material. Most often stents are made out of metal, but they can also be made out of plastic. Using endoscopy, a stent can be placed into the esophagus across the length of the tumor.

The success of the stent depends on the type of stent that is used and where it is placed. Stents will relieve trouble swallowing in most patients. They are often used after other endoscopic treatments to help keep the esophagus open.